Dr. Holly Hoefgen shares when you should take your daughter to the gynecologist for her first time, how to help your daughter through her period(s), and important information on the HPV Vaccine.
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Reproductive Health and Your Teen
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Learn more about Holly Hoefgen, MD
Holly Hoefgen, MD
Holly Hoefgen, MD, is a pediatric and adolescent gynecologist. Her areas of specialty include primary ovarian insufficiency, abnormal menstruation, endometriosis, vulvar dystrophy, polycystic ovary syndrome, contraception and general gynecologic health, as well as fertility preservation for children and adolescents.Learn more about Holly Hoefgen, MD
Transcription:
Dr. Holly Hoefgen (Guest): Hi, my name is Holly Hoefgen and I’m a Washington University Pediatric and Adolescent Gynecologist and I’m a Mom Doc at St. Louis Children’s Hospital.
Melanie Cole (Host): Welcome, you’re listening to Mom Docs, the podcast from St. Louis Children’s Hospital. I’m Melanie Cole, and today we’re talking about reproductive health and your teen, and as someone with a 16-year-old daughter, I got a lot of questions Dr. Hoefgen. So the biggest first question, when do we take our daughter to the gynecologist for the first time?
Dr. Hoefgen: Yeah, that’s a great question. So the American College of OB/GYN does have some recommendations on that, and they say an initial visit for reproductive health screening should happen sometime between the ages of 13 and 15 but that’s going to vary a little bit depending on if you have any gynecologic concerns or problems with menstrual cycles or anything prior to that age, then it would be good to come and see the gynecologist before that if there’s any specific gynecology issues.
Host: Yikes, I guess I’m running a little late then because my daughter’s 16 and I haven’t gotten her in there yet, but I’m actually as a mom, kinda excited for her to do that because it gives them an entrance into that world of womanhood. What should they expect? Because I don’t remember mine. I don’t know if you remember your first appointment. What should they expect?
Dr. Hoefgen: Yeah and I mean some of this will vary depending on the gynecologist you come to, and depending on if you’re coming for that initial sort of visit of understanding and getting to know your provider, but in general at the first visit, it’s really important to start this physician/patient relationship with your daughter and a gynecologist. So it’s really just about building trust and counseling. Mainly the patients and the parents right? On discussion of what are healthy behaviors, what is healthy women’s health, and then we’re also dispelling a lot of myths and fears in patients and families about what a gynecologist is and what we would actually do and also just some different myths and fears in female reproductive health and sexual health in general. So a lot of the visit is discussion and getting an understanding of what you would be looking for as we move forward in the future. But basically we would start by talking to both the patient and her trusted adult together. So most of the time that’s mom and daughter, but not always and then we would also talk to the patient by themselves for some time so they can have a confidential time as well to gain that experience with their physician, and then as far as what we do for an exam. That again is variable based on the patient and their experience and how they feel about moving forward with exam, but we would always do a general exam. Often we would start doing visual breast exams at that time, and in many patients we’ll do just and external genital exam, but there’s really hardly ever any reason to do a true internal speculum exam like most of us as moms might be worried about or preparing for. We can help with almost any gynecologic concerns without doing that speculum exam, and we would really just reserve it for patients that truly needed to have something invasive like that done.
Host: Then when do they get their first Pap smear, and as a result of the Gardasil, you know the HPV. Does that change? Are there different guidelines for now when they’re going to get Pap smears versus getting tested for HPV – what happens in that respect?
Dr. Hoefgen: Yeah those are excellent questions, and that actually has changed quite a bit from when most of us as parents were familiar with getting Pap smears as younger adults and teenagers, the recommendation used to be to start at age 18 or when girls were a few years after starting sexual activity, but the more that we have learned about cervical cancer and about the HPV virus that causes it, we’ve actually realized that’s not necessary and that most young patients, even those patients who get an HPV infection, tend to clear it very readily. So the newer recommendations are to start Pap smears at the age of 21, regardless whether or not girls have had relationships in the past or not, and the only times we would really be doing Pap smears earlier than that would be in certain patients who may have some severe immunodeficiency such as those girls with HIV or something like that, but otherwise for our general population we start at 21 years old, and the HPV vaccine is very important and very good and I would highly recommend that, but it doesn’t change the recommendations as far as beginning Pap smears. We would still start Pap smears at the same time regardless of whether girls have had the HPV vaccine, but having that HPV vaccine does decrease their risk that those Pap smears will come back abnormal.
Host: That’s great information, thank you so much for that, Dr. Hoefgen. What about our daughter’s periods? Are we as moms to be concerned with them if they haven’t gotten them yet or if they’re very heavy? What do we want to teach our daughters about their periods and keeping track of them and maybe even keeping an eye on them for anything that’s not normal?
Dr. Hoefgen: Yeah exactly, and this is a lot of questions that we get in our office, right? Like when should the period come and when it does come how often should it come? There are a few sort of points to look for as girls grow and develop. We expect on average most girls tend to get their periods around the age of 12 to 12.5, but we would really want to see them and track that and make sure from a medical perspective that they were doing fine if girls don’t start their period by the age of 15. That’s really the red flag for that. Some girls may be evaluated earlier. So if girls are 13 and they haven’t had their period but they also haven’t had any developments of breasts or pubic hair, those type of things, we would actually see them a little bit earlier because we usually expect that girls get their period about 2 years after they start getting breasts, so if we don’t see breast development either, then we would usually look at that a little bit earlier. But then for girls that do get their periods, then we kind of have just this discussion of what reasonable expectations are. We know that in the first couple years after starting the periods that girls are thought to be irregular with their periods just because they’re not necessarily ovulating all the time like an adult woman might be. But sometimes in the past that’s turned into well anything can happen in that first couple years, and that’s not actually true. That irregularity should still fall somewhere between about 25 and 45 days that girls are having periods, so if the periods are too close together or too far apart, we still do want to see girls even if they’re in that first couple years. So I tend to use an easy to remember tool with my patients that we call the 1, 10, 20 rule. So the 1 is if you’re going through more than a pad an hour. The 10 is if the period lasts longer than 10 days, which is actually 7-10 days but 10’s much easier to remember, and then if 20 means that if day 1 of one period to day 1 of the next period is 20 days or less, then we would also want to talk to patients. So those are concerns where you might be having too many periods, they’re too close together, they’re too long and we would worry that a blood count might be going down or iron levels might be going down, things like that, and then on the opposite end, if you ever go more than 90 days without a period, then that’s also concerning, even in that first couple years after having your period. So those are just some basic rules that moms can kind of look at, and really having your daughter’s track their menstrual cycles is very important. We used to hand out little pink cards with calendars on them and ask girls to keep track of them, but nowadays no one wants that because you can get everything on an app, so there are a number of really great apps that girls can get on their phone that are free, that are aimed at young adults and adolescents and just putting that onus on them to take care of that part of their health can be very rewarding in the end.
Host: Great information and so important for us to hear for our daughters to get them going into something that they’re not going to really get to stop doing until they’re in menopause and beyond.
Dr. Hoefgen: Right, they’re like it’s coming any day, exactly.
Host: Really, they’re always excited that it’s coming and I’m just like don’t be in such a rush because it’s every month and you can’t really get away from it. So tell us a little bit as we wrap up about the other services that are available at St. Louis Children’s Hospital and the Women and Infant Center for Adolescent Girls and Boys.
Dr. Hoefgen: Yeah, so we see patients both pediatric, adolescent, and young adult. So in our general clinic here at Washington University for Gynecology we’ll see patients from 0 up until age 24 for all gynecologic health concerns. So if patients are having problems with their menstrual cycle, if they’re interested in discussion about contraception and sexual health, or if they’re having just irritation, itching in the vulvar area, we do a lot of that, and we also see patients for other concerns of the female anatomy such as masses in the ovaries or congenital anomalies or trauma of the genitalia. So there’s a lot that we see girls for in this younger age group that you often don’t think about, but everything that can happen to us as an adult can in general happen to us as an adolescent and often even as a young child so there are a lot of things that we would see girls for. Also kind of more specific things that we do in the pediatric and adolescent clinic is we are partnering with our oncology colleagues and St. Louis Children’s Hospital to offer gynecology and fertility services to patients that are going to be undergoing cancer treatments or bone marrow transplants, so we’re seeing those patients before their treatment to talk about things that they can do to help with their fertility in the future, and that starts as young as a young infant, up until our pediatric/adolescent/young adult age group and then we’re also going to be working with our partners in the gender dysphoria center to provide services for patients in their clinic as well. So a lot that I think we have going on that can help patients in a variety of different aspects of life.
Host: Thank you so much Dr. Hoefgen, always a pleasure to have you on our shows. You are such a great educator and today was no different. Thank you so much for being with us. If you found this podcast informative as I did, please share on your social media and be sure to check out all the other helpful podcasts in our library. Head on over to the website at stlouischildrens.org to get connected with one of our providers. Until next time, this is Melanie Cole.
Dr. Holly Hoefgen (Guest): Hi, my name is Holly Hoefgen and I’m a Washington University Pediatric and Adolescent Gynecologist and I’m a Mom Doc at St. Louis Children’s Hospital.
Melanie Cole (Host): Welcome, you’re listening to Mom Docs, the podcast from St. Louis Children’s Hospital. I’m Melanie Cole, and today we’re talking about reproductive health and your teen, and as someone with a 16-year-old daughter, I got a lot of questions Dr. Hoefgen. So the biggest first question, when do we take our daughter to the gynecologist for the first time?
Dr. Hoefgen: Yeah, that’s a great question. So the American College of OB/GYN does have some recommendations on that, and they say an initial visit for reproductive health screening should happen sometime between the ages of 13 and 15 but that’s going to vary a little bit depending on if you have any gynecologic concerns or problems with menstrual cycles or anything prior to that age, then it would be good to come and see the gynecologist before that if there’s any specific gynecology issues.
Host: Yikes, I guess I’m running a little late then because my daughter’s 16 and I haven’t gotten her in there yet, but I’m actually as a mom, kinda excited for her to do that because it gives them an entrance into that world of womanhood. What should they expect? Because I don’t remember mine. I don’t know if you remember your first appointment. What should they expect?
Dr. Hoefgen: Yeah and I mean some of this will vary depending on the gynecologist you come to, and depending on if you’re coming for that initial sort of visit of understanding and getting to know your provider, but in general at the first visit, it’s really important to start this physician/patient relationship with your daughter and a gynecologist. So it’s really just about building trust and counseling. Mainly the patients and the parents right? On discussion of what are healthy behaviors, what is healthy women’s health, and then we’re also dispelling a lot of myths and fears in patients and families about what a gynecologist is and what we would actually do and also just some different myths and fears in female reproductive health and sexual health in general. So a lot of the visit is discussion and getting an understanding of what you would be looking for as we move forward in the future. But basically we would start by talking to both the patient and her trusted adult together. So most of the time that’s mom and daughter, but not always and then we would also talk to the patient by themselves for some time so they can have a confidential time as well to gain that experience with their physician, and then as far as what we do for an exam. That again is variable based on the patient and their experience and how they feel about moving forward with exam, but we would always do a general exam. Often we would start doing visual breast exams at that time, and in many patients we’ll do just and external genital exam, but there’s really hardly ever any reason to do a true internal speculum exam like most of us as moms might be worried about or preparing for. We can help with almost any gynecologic concerns without doing that speculum exam, and we would really just reserve it for patients that truly needed to have something invasive like that done.
Host: Then when do they get their first Pap smear, and as a result of the Gardasil, you know the HPV. Does that change? Are there different guidelines for now when they’re going to get Pap smears versus getting tested for HPV – what happens in that respect?
Dr. Hoefgen: Yeah those are excellent questions, and that actually has changed quite a bit from when most of us as parents were familiar with getting Pap smears as younger adults and teenagers, the recommendation used to be to start at age 18 or when girls were a few years after starting sexual activity, but the more that we have learned about cervical cancer and about the HPV virus that causes it, we’ve actually realized that’s not necessary and that most young patients, even those patients who get an HPV infection, tend to clear it very readily. So the newer recommendations are to start Pap smears at the age of 21, regardless whether or not girls have had relationships in the past or not, and the only times we would really be doing Pap smears earlier than that would be in certain patients who may have some severe immunodeficiency such as those girls with HIV or something like that, but otherwise for our general population we start at 21 years old, and the HPV vaccine is very important and very good and I would highly recommend that, but it doesn’t change the recommendations as far as beginning Pap smears. We would still start Pap smears at the same time regardless of whether girls have had the HPV vaccine, but having that HPV vaccine does decrease their risk that those Pap smears will come back abnormal.
Host: That’s great information, thank you so much for that, Dr. Hoefgen. What about our daughter’s periods? Are we as moms to be concerned with them if they haven’t gotten them yet or if they’re very heavy? What do we want to teach our daughters about their periods and keeping track of them and maybe even keeping an eye on them for anything that’s not normal?
Dr. Hoefgen: Yeah exactly, and this is a lot of questions that we get in our office, right? Like when should the period come and when it does come how often should it come? There are a few sort of points to look for as girls grow and develop. We expect on average most girls tend to get their periods around the age of 12 to 12.5, but we would really want to see them and track that and make sure from a medical perspective that they were doing fine if girls don’t start their period by the age of 15. That’s really the red flag for that. Some girls may be evaluated earlier. So if girls are 13 and they haven’t had their period but they also haven’t had any developments of breasts or pubic hair, those type of things, we would actually see them a little bit earlier because we usually expect that girls get their period about 2 years after they start getting breasts, so if we don’t see breast development either, then we would usually look at that a little bit earlier. But then for girls that do get their periods, then we kind of have just this discussion of what reasonable expectations are. We know that in the first couple years after starting the periods that girls are thought to be irregular with their periods just because they’re not necessarily ovulating all the time like an adult woman might be. But sometimes in the past that’s turned into well anything can happen in that first couple years, and that’s not actually true. That irregularity should still fall somewhere between about 25 and 45 days that girls are having periods, so if the periods are too close together or too far apart, we still do want to see girls even if they’re in that first couple years. So I tend to use an easy to remember tool with my patients that we call the 1, 10, 20 rule. So the 1 is if you’re going through more than a pad an hour. The 10 is if the period lasts longer than 10 days, which is actually 7-10 days but 10’s much easier to remember, and then if 20 means that if day 1 of one period to day 1 of the next period is 20 days or less, then we would also want to talk to patients. So those are concerns where you might be having too many periods, they’re too close together, they’re too long and we would worry that a blood count might be going down or iron levels might be going down, things like that, and then on the opposite end, if you ever go more than 90 days without a period, then that’s also concerning, even in that first couple years after having your period. So those are just some basic rules that moms can kind of look at, and really having your daughter’s track their menstrual cycles is very important. We used to hand out little pink cards with calendars on them and ask girls to keep track of them, but nowadays no one wants that because you can get everything on an app, so there are a number of really great apps that girls can get on their phone that are free, that are aimed at young adults and adolescents and just putting that onus on them to take care of that part of their health can be very rewarding in the end.
Host: Great information and so important for us to hear for our daughters to get them going into something that they’re not going to really get to stop doing until they’re in menopause and beyond.
Dr. Hoefgen: Right, they’re like it’s coming any day, exactly.
Host: Really, they’re always excited that it’s coming and I’m just like don’t be in such a rush because it’s every month and you can’t really get away from it. So tell us a little bit as we wrap up about the other services that are available at St. Louis Children’s Hospital and the Women and Infant Center for Adolescent Girls and Boys.
Dr. Hoefgen: Yeah, so we see patients both pediatric, adolescent, and young adult. So in our general clinic here at Washington University for Gynecology we’ll see patients from 0 up until age 24 for all gynecologic health concerns. So if patients are having problems with their menstrual cycle, if they’re interested in discussion about contraception and sexual health, or if they’re having just irritation, itching in the vulvar area, we do a lot of that, and we also see patients for other concerns of the female anatomy such as masses in the ovaries or congenital anomalies or trauma of the genitalia. So there’s a lot that we see girls for in this younger age group that you often don’t think about, but everything that can happen to us as an adult can in general happen to us as an adolescent and often even as a young child so there are a lot of things that we would see girls for. Also kind of more specific things that we do in the pediatric and adolescent clinic is we are partnering with our oncology colleagues and St. Louis Children’s Hospital to offer gynecology and fertility services to patients that are going to be undergoing cancer treatments or bone marrow transplants, so we’re seeing those patients before their treatment to talk about things that they can do to help with their fertility in the future, and that starts as young as a young infant, up until our pediatric/adolescent/young adult age group and then we’re also going to be working with our partners in the gender dysphoria center to provide services for patients in their clinic as well. So a lot that I think we have going on that can help patients in a variety of different aspects of life.
Host: Thank you so much Dr. Hoefgen, always a pleasure to have you on our shows. You are such a great educator and today was no different. Thank you so much for being with us. If you found this podcast informative as I did, please share on your social media and be sure to check out all the other helpful podcasts in our library. Head on over to the website at stlouischildrens.org to get connected with one of our providers. Until next time, this is Melanie Cole.